Christopher Boorse is well-known for his development of the
Biostatistical Theory, a naturalistic account of disorder as dysfunction. His
account continues to be widely discussed, but – although it is meant to apply
to both somatic and mental disorder – it has received comparatively little attention
in literature on mental disorder.

This one-day conference and lecture offer the unique opportunity
to see Chris person; he has not been in Europe for over thirty years. It will
also give a chance to discuss whether and how his account can be extended to
apply to psychiatry. The conference and lecture should be of interest to
philosophers of medicine, psychiatry, science and mind, as well as to
psychiatrists, medical professionals and other health-care practitioners with
an interest in philosophy.

Conference Program:

10:45 – 11:15

Registration; Coffee and Tea

11:15 – 12:15

Thomas Schramme, Professor
of Practical Philosophy, University of Hamburg.

“Mental Disorder as Mental Dysfunction”

12:15 – 1:30

Lunch

1:30 - 2:30

Elselijn Kingma, Wellcome
Research Fellow, King’s College Centre for Humanities and Health/Department of
Philosophy.

This conference and lecture are
organised jointly by the Department of Philosophy/Centre for Humanities and
Health, King’s College London. Attendance is free, but please do confirm your attendance by sending an
email to Julia Howse [Julia.howse@kcl.ac.uk] so we can judge numbers for
catering.

Friday, 16 November 2012

I’ve mentioned here before that Laura Buckley is
researching older people’s conceptions of wellbeing. She is exploring this
through photographs taken by participants and using narrative analysis to
explore their discussions of the significance of the pictures. In a supervision
with Joy Duxbury and Bernie Carter this week, I was struck by the hint of a
worry which is related to a previous worry.

The previous worry was this. Those who use narrative analysis
in qualitative social science (let’s call them ‘narrative theorists’ and the
approach ‘narrative theory’ for speed) seem to be tempted by two claims either
one of which may be true but probably not both. They often stress the ubiquity of narratives
(“Even a conversation at a bus-stop is a narrative”). But they also chart the
internal structure of narratives (“All narratives have a moral” “There is always a Trickster”). It seems – albeit
contingently – highly unlikely both are true. The more the interesting claims
about the internal structure of narratives (eg the division into say seven
elements of any narrative), the less likely that narratives are ubiquitous or
of universal application to apparently non-narrative social situations (eg all
conversations at bus-stops). One would expect, rather, it to be true of
particular literary genres. The more the appeal to universal application, the
less likely that all utterances in social situations form a narrative with a
particular internal structure. My entirely informal survey of discussions with
narrative theorists (not at UCLan, I hasten to add) is a fondness, nevertheless, for both
claims.

The new worry – which is less straight forward and may be
unfounded – goes something like this. If narrative theory really charts
interesting and contingent aspects of the structure of the utterances of social
science subjects then it contrasts with, say, a grammar theorist’s view. A
theory of the grammar of a language – a grammar – is a sizeable achievement. But
it does not provide an insight into the content of utterances: just the linguistic
vehicles for expressing them. By contrast, the narrative theorist says things
like ‘every narrative has seven elements:...’, which could obviously be false.
If what makes the grammarian’s claims true is the structure of English, say, or
the structure of English as spoken in C21 Preston, or the innate structure of
human depth grammar, what would make the narrative theorists claims true?

Here is a thought. What they chart, intellectually riskily
like any brave social scientist, are the contingent social practices of, say,
C21 conversational participants. We can imagine the participants in contemporary Preston initially explicitly following some rules of good style in the way that one might follow
the rules of haiku or lipogram construction and then this becoming second
nature. The narrative theorists chart these conventions. But now suppose that we are interested in the views of wellbeing expressed by these subjects in conversations and that we ask them. If we attend to the form of the narrative (every narrative has a
moral; every narrative has seven elements:..) that they offer in reply we run two related risks.

First,
we will be examining not the structure of the subjects’ conception of wellbeing
but rather the structure of their conversational engagement and that is looking
in the wrong place. Second, if we do not realise this and set out the structure
of what results (the moral; the seven elements etc) we run the risk of thinking
that their conceptions of wellbeing are in some way narratively structured when
in fact it is merely a contingent way of giving them expression. (Imagine that we investigate two groups who reply on two different kinds of narrative to set out their conceptions of wellbeing. Have they distinct conceptions of wellbeing or the same conception undergoing different conventional forms of expression?) The way to
avoid this is to model narrative structure on grammatical structure. But if so,
the substantive claims about narrative structures will be undermined.

(This worry parallels a worry about the relationship of the
conceptually structured realm of appearance and the underlying noumenal realm
on a two world reading of Kant. Once the noumenal realm is part of a composite
picture, the process of conceptualising it in one way (rather than another) looks
to be distorting of what is really real. One needs to think that the structure is not a substantive mediation but merely a way of letting the reality shine through.)

Thursday, 8 November 2012

At a phenomenology
reading group set up by my colleague Gill Thomson today we discussed a couple
of papers by John Paley criticising the use of phenomenology in nursing
research and more generally an approach to qualitative social science that
draws on what he called ‘constructivism’. In the main, and understandably,
those attending the reading group were unimpressed by his arguments but I was
not able to get a clear understanding of a view which seemed widely held in the
group: that a view or approach reasonably called ‘constructivism’ falls out of quite
a general qualitative social science approach and is itself of general applicability,
saying something substantial about the world. Someone suggested that interpretivism
stood to constructivism as epistemology stands to ontology. But though that might
help, we still need to know what both are.

One problem is knowing what interpretation is. There seemed to be the
thought today that interpretation is ubiquitous and that it has to do with meaning.
But the first thought is surely odd and unnatural. Interpretation is not ubiquitous. It is not the only way to react to meaning. I mayinterpretan ambiguous smile as friendly or a David Lynch film as about death.
But I do not interpret the stop sign - in the UK - as telling me to stop. Given
my background, my induction into relevant practices, I see that straight off. Imagine
trying to get off a reckless driving charge by saying: well that is not how I interpreted
the sign. (By contrast, if one went the wrong way up a road as a result of misreading
a map one could say that one interpreted the map wrongly. Some people at least react to maps and signs differently.) So not all responding
to meaning is normally called ‘interpretation’.

Still we might introduce it as a technical term and say: all responding
to meaning is to be called ‘interpretation*’. But if so, not all interpretation*
so defined involves construction. Meaning can or does involve construction if we set up a bit of a language. When Lois and I baptised my cat ‘Sootica’, we set up, established,
or perhaps one could say, if a still little oddly, weconstructedthe meaning
that that word would now have on our lips. It now goes proxy for a particular cat.
Using it we speak of her. But if Lois, cooking fish, shouts "Don't let Sootica
into the kitchen" I do notconstructthe meaning of that utterance. She has told me what not to do. I hear it in her words. It is
no excuse if I let the cat in to say that I put quite a different construction on
those words. In normal circumstances, they could not bear a different interpretation.

With a David Lynch film I may spend some time constructing an interpretation
to tie up all the loose ends. Or I may construct a Freudian or Marxist reading.
But such construction is quite distinct from hearing what Lois said. In court, the
judge might ask: ‘Is it true that she told you to keep the cat out?’ but will not ask,
or at least not insist on an answer to, whether it is true that the Lynch film is
Marxist. S/He might ask whether it is widely interpreted in that way, or could be. Such interpretations are quite niche notions.(Interestingly, things might be contingently different these days and in some quarters at least about Freudianism, such is the greater lingering influence of Freud over Marx in cultural analysis. Suppose the judge asks whether Mulholland Drive is a Freudian film and takes it for granted that there is a fact of the matter, obviously. To the extent to which the answer is obvious, though, and not a matter of careful construction of an interpretative schema, it is also no longer a matter of interpretation. To the regular Lynchian, the film says Freud as the stop sign says stop.)

One might say that it is just obvious that meaning is constructed,
however. That is, meaning is like being married, or a university lecturer or a capital
city: a social construct. Even in Lois’ shout,
we jointly make up the meaning of that claim. But if so, we pay a high price. Take
a sentence describing the state of my fridge in the future eg "tomorrow it
will have two or more pints of milk". If that sentence is not sufficient to
mean what it says, if it requires the assistance of a fresh construction each time
it is used, then there is no fact that it expresses. So there is no fact of the
matter about whether tomorrow my fridge will have two pints of milk. (Happy antirealists
about the future can pick a present tense sentence.) Constructivism about meaning
seems to lead to global idealism. (If one objects that this though only
threatens the sentences used to state facts not the facts themselves one will owe
an account of facts which is not just what a true sentence states. I can’t think
of any.)

More familiarly, if meaning is socially constructed by being a convention,
are the consequences of that convention also fixed by convention or do they follow
from the meanings now fixed and in need of no further construction? If the former,
this will transform maths or logic since we will never be surprised by the remote
logical consequences of what we think. We will always make up the answer to any
new sum rather than see what it already is. Conducting classical music will be more
like free jazz. Reading a poem will be writing a poem etc. If the latter, there
are some key facts about meaning which are not constructed. They may be the ones
that need no interpretation: the stop sign again.

So I am left with the worry that whilst meanings or interpretations
may sometimes be constructed, they are not all constructed. And so constructivism
cannot generally hold. So what is it?

Wednesday, 7 November 2012

I have been to the third of a three day conference / workshop on
EBM and VBP organised by Michael Loughlin and Phil Hutchinson (pictured) at MMU, Cheshire.
My talk, assembled sadly (and rudely because Rupert Read had to respond to it)
at the last minute, started from a single comment in Bill Fulford's reply to a
commentary I had written on VBP for a special issue exited by Michael. In it, I
suggested that one can think of Fulfordian VBP as a conjunction of three
claims.

1: Values are implicated in diagnosis as well as treatment
2: Principles are insufficient for value judgements
3: The emphasis is on good process rather than right outcomes

I then expressed doubts about the consistency of the third
procedural claim with the idea that VBP is proposed with normative force. Instead,
I suggested that one can have pretty much everything one wants by combining the
first two with a particularist model of value judgements in which value
judgements aim to track real evaluative particulars inhering in situations.
But, I suggested in the commentary, a diagnosis of why Bill had not himself
adopted this version.

If there is sufficient agreement about values then codifications
– whether ethical or legal or other – can contingently be formulated. But the
explanation for such agreement is not that there are real values out there that
command the agreement of right thinking people. That approach – particularism –
which I favour perhaps smacks of authoritarianism and, in the context of
medicine, may recall the dangers of totalitarian psychiatry. [Thornton 2011:
**]

And indeed Bill agreed with this worry and hence motivation in
his, as yet unpublished, reply.

[A]uthoritarianism in the guise of totalitarian psychiatry (the
imposition of a pre-set view of ‘good outcomes’) was the basis of some of the
worst abuses of medical practice in the twentieth century [Fulford draft reply]

The phrase ‘imposition of a pre-set view of “good outcomes”’
might carry either of two meanings, however. It might mean the imposition of a
prejudiced view by powerful people. That would fit the label 'authoritarian'.
But it would not justify the rejection of the particularist in favour of the
liberal view. Or it might mean that the process of deliberation of VBP answers
to, is disciplined by, a or the right or good outcome. But if the latter, why
think that responding to independently existing good outcomes is authoritarian?
And can we understand VBP without ‘authoritarianism’?

One motivation for that might be drawn from Rorty's assimilation
of the authoritarianism of religious abasement to the objectivity of taking
empirical and value judgement as answering to a worldly 'other'. Here is
McDowell's summary of Rorty's view (to which Rorty does not object).

The sense of sin from which Dewey freed himself was a reflection
of a religious outlook according to which human beings were called on to humble
themselves before a non-human authority. Such a posture is infantile in its
submissiveness to something other than ourselves. If human beings are to
achieve maturity, they need to follow Dewey in liberating themselves from this
sort of religion of abasement before the divine Other. But a humanism that goes
no further than that is still incomplete. We need a counterpart secular
emancipation as well...
What Rorty takes to parallel authoritarian religion is the very idea that in
everyday and scientific investigation we submit to standards constituted by the
things themselves, the reality that is supposed to be the topic of the
investigation. Accepting that idea, Rorty suggests, is casting the world in the
role of the non-human Other before which we are to humble ourselves. Full human
maturity would require us to acknowledge authority only if the acknowledgement
does not involve abasing ourselves before something non-human. The only authority
that meets this requirement is that of human consensus. If we conceive inquiry
and judgment in terms of making ourselves answerable to the world, as opposed
to being answerable to our fellows, we are merely postponing the completion of
the humanism whose achievement begins with discarding authoritarian religion.
[McDowell 2000: 109-10]

This view is motivated by a number of other views which are not
closely connected to VBP. For example, Rorty's antirepresentationalism rules
out not only views within the philosophy of mind but more generally views about
the relation of thought and world and hence the need instead for solidarity
rather objectivity. But even if one did not take a view on that, one might
still think that value judgements are affected and infected by a deep
contingency. It is only because of contingent features of our natures and
cultures that we are in any position to make the judgements we do. Further,
value judgements can be hard in this sense: even having deployed very thorough
argument and debate, there seems to be no guarantee of agreement on ethical
matters. There are echoes in this of Fulfordian VBP.

So one way to motivate a rejection of authoritarianism in VBP,
construed merely as the idea of being disciplined by some sort of right or good
outcome, is to take note of the underlying contingency of value judgements and
to conclude from this that the idea of objectivity in this area makes no sense.

If so, however, there is an alternative to be found in what
McDowell goes on to outline. The key idea is that neither the underlying
contingency nor the idea that value judgements are hard rules out objectivity.

One aspect of the immaturity that Rorty finds in putting
objectivity rather than solidarity at the focus of philosophical discourse is a
wishful denial of a certain sort of argumentative or deliberative predicament.
On the face of it, certain substantive questions are such that we can be
confident of answers to them, on the basis of thinking the matter through with
whatever resources we have for dealing with questions of the relevant kind (for
instance, ethical questions)... But even after we have done our best at
marshalling considerations in favor of an answer to such a question, we have no
guarantee that just anyone with whom we can communicate will find our answer
compelling. That fact - perhaps brought forcibly home by our failing to
persuade someone - can then induce the sideways glance, and undermine the
initial confidence. Rorty's suggestion is that the language of objectivity reflects
a philosophical attempt to shore up the confidence so threatened, by wishfully
denying the predicament. The wishful idea is that in principle reality itself
fills in this gap in our persuasive resources.
Any rational subject who does not see things aright must be failing to
make proper use of humanly universal capacities to be in tune with the
world. If we fall into this way of
thinking, we are trying to exploit the image of an ideal position in which we
are in touch with something greater than ourselves – a secular counterpart to
the idea of being at one with the divine – in order to avoid acknowledging the
ineliminable hardness of hard questions, or in order to avoid facing up to the
sheer contingency that attaches to our being in a historically evolved cultural
position that enables us to find compelling just the considerations we do find
compelling.

Here too we can make a separation. This wishful conception of attunement with
how things really are, as a means of avoiding an uncomfortable acknowledgement
of the limitations of reason and the contingency of our capacities to think as
we believe we should, can be detached from the very idea of making ourselves
answerable to how things are. We can join Rorty in deploring the former without
needing to join him in abandoning the very idea of aspiring to get things
right... [McDowell 2000: 112]

So this suggests two ways of thinking about VBP and
authoritarianism. One can reject the latter, construed as a commitment to right
outcomes independent of any particular instance of the process of deliberation,
and put the emphasis on process or solidarity and motivate it by invoking
something like Rorty's rejection of abasement to the Other. One can appeal to
this in the case of value judgements in particular because of their connection
to the contingencies of human subjectivity and the omnipresence of hard
judgements.

But, if so, one will need to shore up that picture against the
objection that it does not follow from those motivations alone. That is, one
can combine the first two elements of VBP, which I outlined at the start, with
a denial of a constitutive role of process and maintain that even in VBP value
judgements are disciplined by evaluative particulars. One way to fill this out
is to borrow McDowell's sketch in which the realm of values is in a
transcendental harmony with our subjectivity. One needs to have a particular
kind of mind and life to have one's eyes open(ed) to this tract of reality, as
McDowell might say. (So the independence of process and outcome is at the level
of instances. ) Such an alternative is at least available to VBP at the cost of
adopting, and defending, a particularist metaphysics of values.

That is to set out two approaches with their distinct costs. But
it still seems to me that there is reason to favour the latter. The first
reason is the objection that proposing or supporting VBP itself presupposes a
value which does not seem simply to await the VBP process. The second is that
VBP aims at a balance of values and, third, is a skill. But surely not just any
balance - such as one imposed by force - will do, but the right, or at least a
good, outcome? And a skill requires some conception of discipline if it can be
practiced. So I still think that a particularist reading of VBP is to be preferred
over the more radical, liberal sense.

Interestingly, Rupert Read agreed with the critical thrust but thought that there would be no logical space for the modest particularist
modification I proposed. Rather, once proceduralism was replaced with a thought
that any form of VBP was held in place only at the cost of some substantial
value judgements then a critical assessment and justification of them would
have to take account of the point and context of healthcare. So the replacement account
would inflate to stop nowhere short of a teleological account of a flourishing
orientated medicine: FlOM. Wary of substantial theory building, I was not sure
I wanted to sign up yet for such a utopian reworking of VBP. But I will wait to
see how he and Phil articulate and develop FlOM.